When does the foreskin separate naturally?

Normally the inner layer of the foreskin (prepuce) adheres to the glans (tip of the penis) at birth. Separation occurs slowly over the next few years, starting at the tip and progressing back.

The time of foreskin separation is quite variable, but the majority of boys will have foreskin that they can fully retract by the time they are 16 years old. No effort should be made to retract the foreskin until separation occurs. Thereafter the foreskin should be retracted at every bath or shower and cleaned as part of normal male hygiene. Until complete separation occurs, episodes of redness, smegma collections, and ballooning are common. They can usually be managed with conservative measures.

Conditions that may occur until foreskin separation is complete

Smegma: This is the white, cheesy material secreted by the glans that sometimes collects in little cyst-like pockets. If left alone, these will empty on their own when separation occurs.

Ballooning: Occurs when urine becomes temporarily trapped under the foreskin during urination. This is generally not a problem for boys and no treatment is required.

Balanitis: This is a mild, low-grade inflammation of the foreskin, with redness and discomfort (common with ammonia diaper dermatitis). Proper care of the foreskin usually prevents this. If it keeps coming back, it may be caused by a yeast or bacterial infection. Yeast infections require anti-yeast medication while antibiotics will be required if the infection is bacterial. Talk to your doctor if this is a recurring problem.

Phimosis: Refers to a foreskin that won't retract. If it's just delayed separation and the skin is healthy, nothing needs be done. Beyond age 5 steroid cream can be tried to effect separation.

True pathologic phimosis: This involves fibrosis and scarring near the tip of the foreskin, usually from inflammation or trauma (e.g., trying to retract an unseparated foreskin). Up to 30% of cases may be due to Lichen Sclerosis and may respond to steroid cream. If not, then this is the only absolute indication for circumcision.

Paraphimosis: This condition occurs when the foreskin is retracted and cannot be restored to its resting state, and progressive swelling and pain of the glans ensue. Manual reduction should be done as soon as possible. If the condition is mild, sedation and painkillers should be used. Frequently, however, a general anesthetic is required. Once the foreskin is reduced recurrence is infrequent, and circumcision is probably unnecessary.

Circumcision

Circumcision removes the foreskin, as far as the base of the glans. The glans then becomes squamified (covered in a tougher skin than normal).

Deciding whether or not to circumcise your baby boy is a difficult decision and should not be underestimated. Largely, the decision depends on personal or religious beliefs. The fact that so many adult males are circumcised makes the care of a foreskin uncertain territory for many parents, doctors and other health professionals. Consequently, many parents receive conflicting advice.

If the decision to have a baby circumcised is religious, the operation is generally performed within the first few days of life. However, if the penis is abnormal in any way, requiring that the foreskin be available for subsequent plastic surgery, the procedure should be delayed.

The most common medical reason for performing a circumcision is to remove an unusually tight foreskin that is obstructing the flow of urine.

Is circumcision painful?

Circumcision can be extremely painful and traumatic for a baby. Anesthetics injected into the penis don't always work. Having a needle inserted into the penis is itself painful for a baby, just as it would be for an adult.

Does circumcision have risks?

Risks can include infection, complications from anesthetics, and surgical mistakes. Bleeding can also occur, so circumcision should be delayed or reconsidered if the mother has been taking acetylsalicylic acid (ASA) or anticoagulants, or if a bleeding disorder such as hemophilia runs in the family.

Another risk is that of regret. Some men these days regret the loss of their foreskin at birth without their consent. Some go to great lengths to try and recover a foreskin through stretching and surgery. Therefore, medical ethicists question the practice of performing cosmetic surgery on a newborn, before they can decide for themselves.

Are there any health advantages associated with circumcision?

Some sexually transmitted infections are easier to contract in uncircumcised men with poor hygiene, but most professionals feel that it seems illogical to advocate circumcision to prevent these afflictions. Penile hygiene and safe sex education are likely to have far more effective outcomes.